The Community Care Case Manager RN is responsible for executing a streamlined approach to receiving, triaging, and directing timely, coordinated care. The RN Brings principles and theory with application of critical thinking skills. Serves to support delivery of high quality, timely care to the Veteran receiving services in the community. Assumes responsibility for the coordination of care focused on patient education, self-management, and customer satisfaction throughout the continuum of care.
Major duties: Major Duties include but are not limited to: Assesses, plans, implements, and evaluates the effectiveness of the Veteran's care Follows procedures per established policies and guidelines Influences care outcomes by collaborating with members of the interdisciplinary team Responsible for executing a streamlined approach to receiving, triaging, and directing timely, coordinated care Possesses intimate knowledge of the internal referral care process, clinical review criteria, utilization management standards, clinical documentation requirements, community care regulations, and Veterans Health Administration (VHA) standards and guidelines Uses nursing knowledge and systems theory to assess, organize, facilitate, and guide Veterans through their full range of care options including internal/direct care in Veterans Affairs (VA) and care in the community Serves as a liaison to both internal and community providers and is responsible for managing the care of the Veteran throughout the consult process Supports the medical center's mission to improve timely access to care, ensure Veterans who want to receive care in the community are referred and scheduled into the community, and support the delivery of high quality, timely care to the Veteran receiving community services Work collaboratively within the Office of Integrated Veteran Care (IVC) to triage Request for Services (RFS) to coordinate care processes defined by the IVC Field Guidebook to include developing a care coordination plan, reviewing medical documentation from community providers, communication of care coordination needs, and supporting the Veteran through the completion of the episode of care Influence care outcomes by collaborating with members of the interdisciplinary team both within the VA and in the community Comply with VA-mandated processes and use of health information solutions that serve to assess, document, exchange, and track care coordination information Utilize delegation of authority, if applicable, to function at their highest level of role performance and align high-quality care with key performance indicators to ensure practice standards meet patient care needs Knowledge of professional nursing practice and the ability to apply the nursing process (assessment, diagnosis, outcome identification, planning, implementation, and evaluation) Completes orientation according to expected standards Responsible and accountable for individual nursing practice and seeks direction from others as needed Manages workload as assigned, organizes, and completes own assignments in an efficient and appropriate manner Participates in the development, implementation, and evaluation of interdisciplinary care Knowledge of Veteran/patient driven care, patient experience, satisfaction, and safety Establishes a therapeutic relationship, allowing the patient to attain, maintain or regain optimal function through assessment and treatment Engages patients, families, and other caregivers to incorporate knowledge, values, and beliefs into care planning without judgement or discrimination Knowledgeable of ethical issues related to professional nursing practice and follows established policies of the practice setting Aware of high reliability principles to deliver consistent care and improve patient outcomes Communicates, collaborates, and utilizes leadership principles to perform as an effective member of the interprofessional team Incorporates educational resources/opportunities an